First AD

Second AD

50-year-old male presents with palpable lump in the left breast.


Bilateral mammogram: For the most part, demonstrates characteristic mammographic appearance of gynecomastia, left much greater than right. Flame-shaped, central subareolar mass with prominent linear projections radiating into deep adipose tissue. At inferior aspect on the left, there is a more-welldefined smoothly marginated, lobulated ovoid region, which is not typical for gynecomastia.


Targeted left breast ultrasound: In the left retro-areolar region, typical sonographic appearance of gynecomastia was seen with slightly hypoechoic tissue centered at the nipple, tapering posteriorly. In the area of palpable abnormality, there were multiple well-defined, anechoic structures without internal vascularity on color Doppler interrogation, consistent with multiple breast cysts.


Gynecomastia is defined as "benign proliferation of male breast grandular tissue."

Trimodal age distribution is neonatal, pubertal, and elderly males. It is usually due to an altered ratio of estrogens to androgens (ie, secondary to increased estrogen activity, decreased testosterone activity, or medication related).

Causes are linked to health conditions (hypogonadism, aging, tumors [including testes, adrenal glands, pituitary glands], hyperthyroidism, kidney failure and cirrhosis, malnutrition, and starvation. Medications, such as anti-angrogens (ie, for treatment of prostatic conditions), anabolic steroids and androgens, AIDS medications, anti-anxiety medications (eg, diazepam), tricyclic antidepressants, antibiotics, ulcer medications (eg, cimetidine), chemotherapy, heart medications (eg, digoxin, calcium channel blockers), and street drugs (amphetatimes, marijuana, heroin, methadone) and alcohol have also been linked as causes of gynecomastia.

Gynecomastia is a benign condition and is usually self-limited.

Further inquiry revealed that the patient reported noticing a "milky substance" associated with his palpable breast abnormality -- galactorrhea. This clinical history prompted initial laboratory evaluation, which included checking a prolactin level, revealing hyperprolactinemia. Prolactin level was elevated at 134 (normal range 4.0-15.2). One clinical note also revealed that the patient endorsed a history orf blurry vision. These findings prompted an MRI of the pituitary gland.[[{"type":"media","view_mode":"media_crop","fid":"41027","attributes":{"alt":"","class":"media-image","id":"media_crop_2826643534801","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4261","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":"Sagittal precontrast T1-weighted image reveals enlargement of the pituitary gland, as evidenced by superior convex border.","typeof":"foaf:Image"}}]]

New diagnosis: Gynecomastia secondary to pituitary adenoma (Prolactinoma)


In males, prolactinomas may be completely asymptomatic until there is galactorrhea, compression of the optic chiasm results in visual symptoms, or hypogonadotrophic hypogonadism results in loss of libido and impotence. Prolactinomas are the most common hormone-secreting pituitary tumors.
 

Treatment for gynecomastia secondary to prolactinoma depends on the underlying cause, the aim of treatment would be to reduce prolactin level to normal, reduce tumor size, and restore normal pituitary function.

Medications used to treat prolactinomas are bromocriptine (a dopamine agonist that decreases the synthesis and secretion of prolactin), and cabergoline (a long-acting, nonregot dopamine agonist, is usually better tolerated than bromocriptine, with superiod efficacy profiles). It has been reported that up to 70% of patients who do not respond to bromocriptine respond to cabergoline. Cabergoline has had fewer side effects reported than bromocriptine, but it is more expensive.

This patient was treated with cabergoline. Subsequent prolactin levels were found to be low-normal at 3.4. Follow-up mammogram (A–D) and breast ultrasound (E, F) performed following treatment revealed marked improvement in left gynecomastia, with only minimal residual gynecomastia by mammogram and ultrasound in the left retroareolar region, with resolution of previously seen breast cysts on the ultrasound (E, F).

1. Becker KL. Endocrinology of the Male. 

Principles and Practice of Endocrinology and Metabolism. 

2. Johnson RE, Murad MH. Gynecomastia: patholphysiology, evaluation, and management. 

Image IQ: 50-year-old Male, Palpable Lump on Left Breast

Danielle DeMulder, MD

Erini Makariou, MD